Should Psychiatrists be concerned about future encroachment from NPs, PAs, PsyDs?

[Trousseau]

So I'm a third year. I enjoyed and honored my Psychiatry rotation, and I am interested in a career in Psychiatry. It's time for me to decide on a specialty, and while I'm leaning towards Psych, it's important to have an assessment of the drawbacks* before I choose the field.

One of the issues I have heard of is continued NP and Psychologist encroachment onto the work of Psychiatrists, specifically prescribing medications.

Would you say this will significantly affect the employment outlook for Psychiatry in terms of salaries and positions? Is it something I should consider when deciding my specialty?

------------------------------------------------------------------




*Other drawbacks I am keeping in mind:
1) Relatively low pay
2) Difficult, uncooperative patient population
3) Mental health is a bit of a black box
4) Other physicians look down on you
5) The lay public thinks you do the Freud Couch thing

---

Members don't see this ad.

 

[sunlioness]

Oh god. Can't you just search the forum? Don't make us talk about this again.

No offense intended .... But oh god, please no.


Sent from my iPhone using Tapatalk

 

[Trousseau]

Oh god. Can't you just search the forum? Don't make us talk about this again.

No offense intended .... But oh god, please no.


Sent from my iPhone using Tapatalk

Sorry, I ran a brief search and found nothing, then looked harder and found the good stuff. I apologize.

For those who want to see what's up:

http://forums.studentdoctor.net/thr...y-great-articles-books-in-psychiatry.1066849/

 

[erg923]

Encroachment from psychologists? Is this serious?

 

[Dharma]

Medicine. Everyone wants a piece of the pie... just about every field. Be awesome. No worries. If you build it (I.e. skills) they will come.

 

[OldPsychDoc]

Would you say this will significantly affect the employment outlook for Psychiatry in terms of salaries and positions? Is it something I should consider when deciding my specialty?

No. We've had primary care writing for more psychotropics than psychiatrists for 25 years, and it doesn't change demand for well-trained specialists.

*Other drawbacks I am keeping in mind:
1) Relatively low pay

...relative to surgical specialties perhaps, which aren't what they used to be, but still lots better than primary care. And with better hours.

2) Difficult, uncooperative patient population

Everybody has 'em.

3) Mental health is a bit of a black box

As is everything else in the eyes of the public. Do you think a cardiologist sits around talking about calcium channel dynamics with their patients all the time?

4) Other physicians look down on you

...until you help them deal with one of those "Difficult, uncooperative patients".

5) The lay public thinks you do the Freud Couch thing

Let 'em think it...

Edit: just saw this...we're all doomed.
http://dilbert.com/strip/2015-10-25

 

[sunlioness]

Heh. I'm tired of guys on dates asking, "are you analyzing me right now?" And then following it up with the joke, "let me save you the trouble. I already know I'm crazy"

So maybe get married before you have to tell people that's what you do. Heh.

I usually say, "no, I'm not an analyst". But no one gets it. Maybe that's why I'm still single.


Sent from my iPhone using Tapatalk

 

[bd290]

One of the issues I have heard of is continued NP and Psychologist encroachment onto the work of Psychiatrists, specifically prescribing medications.
*Other drawbacks I am keeping in mind:
1) Relatively low pay
2) Difficult, uncooperative patient population
3) Mental health is a bit of a black box
4) Other physicians look down on you
5) The lay public thinks you do the Freud Couch thing

IMO:
encroachment: considering most of the psychiatrists I know have like 2+ month (child? move that to like 4+) waiting lists to even get an appointment I doubt that NPs and PAs would even make a dent on the level of mental health need that is being unmet at this point in time. I don't follow NP stuff that much but my understanding is that there are more lucrative fields and that psych isn't exactly a big proportion of their graduates. PsyD's prescribing is a political issue - I'll skip my thoughts on the issue and say there are many places where it is unlikely to ever pass.

1: pay - I guess it depends what you're comparing it to, psych had better or ~equal pay of the other specialties I considered (and a better lifestyle than virtually all of them).
2: my thoughts on how "difficult" psych patients are is - at least they have a good excuse. I've met plenty of "difficult" patients who had no good reason for behaving the way they did and I personally found it more annoying than someone who is mentally ill being "difficult."
3: I'm not sure what you mean by "black box?"
4: This hasn't been my experience personally. Qutie the opposite really - I've had several attending general surgeons and internists mention how much they liked the psych service while I was on those specialties and our teams were making consults.
5: the lay public thinks medicine is like Grey's Anatomy.

 

[sunlioness]

The thing about the "difficult patients". You get them in every field. In ours, you have the best training/experience in learning how to most effectively work with them. And most patients aren't "difficult".


Sent from my iPhone using Tapatalk

 

[strangeglove]

Heh. I'm tired of guys on dates asking, "are you analyzing me right now?" And then following it up with the joke, "let me save you the trouble. I already know I'm crazy"

So maybe get married before you have to tell people that's what you do. Heh.

I usually say, "no, I'm not an analyst". But no one gets it. Maybe that's why I'm still single.


Sent from my iPhone using Tapatalk

I usually like to respond to such comments with "I'd be happy to analyze you if you would like to pay my fee."

 

[sunlioness]

Good one!!


Sent from my iPhone using Tapatalk

 

[smalltownpsych]

Last poll I heard indicated that the majority of psychologists don't want prescription authority. I personally think it is a bad idea for us to pursue it as we have much more important things to promote that could benefit the field. Making sure that our own training standards remain high being first and foremost. Besides I don't want to have to deal with the "adderall and benzos and medical marijuana are really the only thing that treats my mental illness" crowd any more than I do already.

 

[PikminOC]

Last poll I heard indicated that the majority of psychologists don't want prescription authority. I personally think it is a bad idea for us to pursue it as we have much more important things to promote that could benefit the field. Making sure that our own training standards remain high being first and foremost. Besides I don't want to have to deal with the "adderall and benzos and medical marijuana are really the only thing that treats my mental illness" crowd any more than I do already.

Remain high?

 

[nitemagi]

I usually like to respond to such comments with "I'd be happy to analyze you if you would like to pay my fee."

Mine is "Well, I charge by the hour." I will also drop in a "I have a pill for that" regularly, as a wink/joke about the profession.

 

[Blitz2006]

So I'm a third year. I enjoyed and honored my Psychiatry rotation, and I was interested in a career in Psychiatry. It's time for me to decide on a specialty, and while I'm leaning towards Psych, it's important to have an assessment of the drawbacks* before I choose the field.

One of the issues I have heard of is continued NP and Psychologist encroachment onto the work of Psychiatrists, specifically prescribing medications.

Would you say this will significantly affect the employment outlook for Psychiatry in terms of salaries and positions? Is it something I should consider when deciding my specialty?

------------------------------------------------------------------




*Other drawbacks I am keeping in mind:
1) Relatively low pay
2) Difficult, uncooperative patient population
3) Mental health is a bit of a black box
4) Other physicians look down on you
5) The lay public thinks you do the Freud Couch thing

1) Relatively Low Pay

Definitely not. If you refer to the thread below, 40% are earning >300k (15% >400k). On par with big guns like Anesthesia/non-IR rads/non-retinal optho/non-interventional cards/general surgery (certain sub-specialties)

http://forums.studentdoctor.net/threads/so-can-we-talk-money.1162751/page-3

And for a more formal compensation study:

http://www.medscape.com/features/slideshow/compensation/2013/psychiatry

This is in 2013, 20% earned more than 300k. And remember, 70% of psychiatrists work less than 40 hours/week, 20% less than 50 hours a week. Scary stat. So if you give a psychiatrist cardiology/general surgery type hours, i'm sure they will be able to clear 350k easily, probably near 400k.

I have close friends in general surgery, and they earn around 300-400k (trauma, breast, endocrine). The big hitters in sub-specialty is colorectal/surg-onc/HPB. So Psych overall stacks up pretty welll even with general surgeons.

Here in the NYC area there are child psychiatrists charging $600/hr, cash only. You can do the quick math on that.

And remember, malpractice for psychiatry is low (10-20k tops). OBGYN in the NYC area pulls in 400-500k, but they also have malpractice of around 180-200k....

So its not just about how much you earn, its also about other stuff like overhead expenses (which in psych is low as well, around 20-25% vs.s specialties like ophtho which is near 40%)

2) Difficult, uncooperative patient population

Everyone has this. You think surgeons never have to deal with messy post-op complications for weeks, precipitating an angry patient population?


3) Mental health is a bit of a black box

Not sure what you mean by this.


4) Other physicians look down on you

Not true at all. On the CL service, I get a lot of compliments from the medicine hospitalists on our work. When I tell people I have an interest in neuropsychiatry, particularly stuff like neuroimaging other specialties are "impressed" by the potential and future of psychiatry.

I think our generation of physicians realize the importance of mental health, as it is becoming a more mainstream subject to talk about.


5) The lay public thinks you do the Freud Couch thing

Again, this is all changing. Image of psychiatry is continue to evolve. Just last week in the NY Times, huge article on Dr. Kane and the big trial for schizophrenia talk therapy.

http://www.nytimes.com/2015/10/20/health/talk-therapy-found-to-ease-schizophrenia.html?_r=0

"Lay public" is becoming more aware of mental health disorders and the importance of pharmacology mixed with psychotherapy.

So talking on the couch isn't a bad thing sometimes.

 

[peppy]

Relatively low pay? Nah. If money is a priority for you, it's out there for psychiatrists. I think one reason psychiatrists may look like they make less is because, as a group, psychiatrists tend to be more interested in lifestyle than making the most money possible. A significant number of psychiatrists do not work full time.

Personally, I chose to take a more demanding and higher paying job right out of residency, with the goal of paying off my debt and squirreling away some retirement money to give myself a good foundation for the future. Once I have done that, I will probably be looking to work part time for the rest of my career. Psychiatry is not bad at all from a lifestyle perspective.

Also, if you don't like working with uncooperative patients, you do have the option of finding a job that mostly deals with voluntary patients who are relatively high functioning. You don't HAVE to work at a facility that takes uninsured patients who are being forced into treatment.

As for any disrespect I get from either non-medical people or other doctors for being a psychiatrist, I will wipe my tears with the fat wads of cash (compared to what most non-doctors make) I am getting as I leave work by 5 pm every day (compared to many other doctors who are stuck with much longer hours). Honestly, I feel INCREDIBLY fortunate that I get to do a job that is fairly interesting (as jobs go) for more money than the vast majority of people in the world can ever hope to make. Even though my job may be a little more demanding than some psychiatrists' job, I still don't have to kill myself working terrible hours.

I grew up in a lower middle class family and most of my friends are still in that sort of situation themselves. When I look at my old friends' lives and the lives of most of my patients, I feel extremely fortunate to have the money and opportunities that I am now getting. There are many, many people out there in this world who work just as hard or harder than doctors do and will never make the kind of money that even a physician in a "low paying" specialty will make. All of us who have had the opportunity to practice medicine in America are extremely fortunate.

 

[F0nzie]

Ok so I thought Blitz may have been exaggerating when he said $600 an hour so I did a bit of research. Certainly nobody can charge that much in my area and stay open for business.

While scoping out going rates in New York I discovered that NPs have can practice independently now. I guess effective this year? And it looks like they are charging $300 an hour cash. Insane! To think that a nurse could make more per hour than a brain surgeon... Completely baffles my mind.

Will NPs take away our jobs or our referrals? Yes, it's not rocket science. But I think we still have another 20-30 years to enjoy this good run before we get flatlined. By then I hope to be sitting under a palm tree with an ice cold beverage.

 

[Doctor Bagel]

Ok so I thought Blitz may have been exaggerating when he said $600 an hour so I did a bit of research. Certainly nobody can charge that much in my area and stay open for business.

While scoping out going rates in New York I discovered that NPs have can practice independently now. I guess effective this year? And it looks like they are charging $300 an hour cash. Insane! To think that a nurse could make more per hour than a brain surgeon... Completely baffles my mind.

Will NPs take away our jobs or our referrals? Yes, it's not rocket science. But I think we still have another 20-30 years to enjoy this good run before we get flatlined. By then I hope to be sitting under a palm tree with an ice cold beverage.

NPs in my state practice entirely independently. As of right now, they definitely make significantly less than psychiatrists in employed positions, but our work loads and responsibilities are similar. In my community gig, the job listings are always for a psychiatrist of a psychiatric NP, and the patient load is identical. Community mental health has already moved to using the term "prescriber" or "LMP" to capture the fact that physicians and NPs are pretty much interchangeable. In my hospital gig, the NPs carry patients independently, and now it's opening up for them to do call, which has politically been a way that hospital systems have protected income for psychiatrists. I think we do offer something extra, but I'm not sure administrator types are going to keep on seeing that down the road. So, yeah, I hate to go against the grain in this thread, but I think there's something to worry about down the road. Maybe not right now but eventually. 20 to 30 years seems a bit optimistic to me. I'm hoping it's not 10.

 

[Dharma]

Looks like the future of medicine just about across the board. No new news there. Be better than the competition. Period. Degrees ain't enough anymore.

 

[Dharma]

That said, is there any legitimate opposition to the political powerhouse of nursing lobbyists? Seems that our only option is "write your local representative." Kind of tough to take down a political machine with fragmented efforts.

 

[Doctor Bagel]

Looks like the future of medicine just about across the board. No new news there. Be better than the competition. Period. Degrees ain't enough anymore.

Easy to say, but who and how is value judged? If you're in private practice, I guess you could say patient feedback and word of mouth count for something. If you're employed, value might just be seeing as many patients as possible and not complaining. Who cares if your treatment plans are not that great? Benzos + stimulants? Why not? 3 different antipsychotics? Whatever. Of course not to say that psychiatrists necessarily do better work than other providers because that's not always true. And yeah, you're right that this is medicine in general.

Of course I'm out here earning more than I anticipated, but I'm a pessimist and feel like something will fall apart. A lot of that is me, but some of it might be reality based.

 

[Blitz2006]

Ok so I thought Blitz may have been exaggerating when he said $600 an hour so I did a bit of research. Certainly nobody can charge that much in my area and stay open for business.

While scoping out going rates in New York I discovered that NPs have can practice independently now. I guess effective this year? And it looks like they are charging $300 an hour cash. Insane! To think that a nurse could make more per hour than a brain surgeon... Completely baffles my mind.

Will NPs take away our jobs or our referrals? Yes, it's not rocket science. But I think we still have another 20-30 years to enjoy this good run before we get flatlined. By then I hope to be sitting under a palm tree with an ice cold beverage.

And this guy that charges $600/hr is in Long Island. Apparently if you go into Manhattan you can find guys charging $800-$900. But this is what he said.

But also remember this is child psych, which i'm surre is higher than adult. And obviously these are not median values, I'm pretty sure he is an outlier. I think the average in Manhattan for adult is around $300-$400, but this is a completely educated guess on my part.

IMHO, there is such a shortage of psychiatrists that I don't think NPs will impact negatively referrals. I don't think its anything like anesthesiologists getting pressure from CRNAs.....

 

[FlowRate]

IMO you should not be considering being a psychiatrist if this is a major concern:

2) Difficult, uncooperative patient population

Working with such patients is the whole game, especially in CL/integrated roles.

 

[Doctor Bagel]

IMO you should not be considering being a psychiatrist if this is a major concern:

Working with such patients is the whole game, especially in CL/integrated roles.

Sometimes true, but I'm not sure we should be in the business of telling people they shouldn't go into psychiatry for having concerns about the work. Not to say I haven't done it before myself ...

 

[FlowRate]

Sometimes true, but I'm not sure we should be in the business of telling people they shouldn't go into psychiatry for having concerns about the work. Not to say I haven't done it before myself ...

Fair enough, my post was perhaps too strongly/succinctly worded. Having concerns is totally appropriate. But if someone doesn't want to work with "difficult" patients, it seems like psychiatry is not going to fulfill that desire.

 

[sunlioness]

Fair enough, my post was perhaps too strongly/succinctly worded. Having concerns is totally appropriate. But if someone doesn't want to work with "difficult" patients, it seems like psychiatry is not going to fulfill that desire.

I think that's the time you start to consider path or rads . . .

 

[Dharma]

Easy to say, but who and how is value judged? If you're in private practice, I guess you could say patient feedback and word of mouth count for something. If you're employed, value might just be seeing as many patients as possible and not complaining. Who cares if your treatment plans are not that great? Benzos + stimulants? Why not? 3 different antipsychotics? Whatever. Of course not to say that psychiatrists necessarily do better work than other providers because that's not always true. And yeah, you're right that this is medicine in general.

Of course I'm out here earning more than I anticipated, but I'm a pessimist and feel like something will fall apart. A lot of that is me, but some of it might be reality based.

Yes, easier to say. But what other option does one have but to max out on potential... and try to enjoy doing so? Game on!

 

[splik]

NPs in my state practice entirely independently. As of right now, they definitely make significantly less than psychiatrists in employed positions, but our work loads and responsibilities are similar. In my community gig, the job listings are always for a psychiatrist of a psychiatric NP, and the patient load is identical. Community mental health has already moved to using the term "prescriber" or "LMP" to capture the fact that physicians and NPs are pretty much interchangeable. In my hospital gig, the NPs carry patients independently, and now it's opening up for them to do call, which has politically been a way that hospital systems have protected income for psychiatrists. I think we do offer something extra, but I'm not sure administrator types are going to keep on seeing that down the road. So, yeah, I hate to go against the grain in this thread, but I think there's something to worry about down the road. Maybe not right now but eventually. 20 to 30 years seems a bit optimistic to me. I'm hoping it's not 10.

cant they also bill the same as psychiatrists in your state?! what a slap in the face.

 

[Doctor Bagel]

cant they also bill the same as psychiatrists in your state?! what a slap in the face.

Yep! Only in psychiatry and primary care. Apparently though my community agency is somehow getting paid more for MD/DO visits than for NP visits. I'm not sure how that works.

 

[F0nzie]

cant they also bill the same as psychiatrists in your state?! what a slap in the face.

Cost savings at its best

 

[Doctor Bagel]

Cost savings at its best

So far we haven't seen wage decreases, but that has to be coming, right? This never works out where everyone just makes more money.

 

[HarryMTieboutMD]

You know, because the AMA is such a remarkably effective lobbying organization in ensuring that physicians are justly compensated and respected... oh wait

 

[Mad Jack]

So I'm a third year. I enjoyed and honored my Psychiatry rotation, and I am interested in a career in Psychiatry. It's time for me to decide on a specialty, and while I'm leaning towards Psych, it's important to have an assessment of the drawbacks* before I choose the field.

One of the issues I have heard of is continued NP and Psychologist encroachment onto the work of Psychiatrists, specifically prescribing medications.

Would you say this will significantly affect the employment outlook for Psychiatry in terms of salaries and positions? Is it something I should consider when deciding my specialty?

------------------------------------------------------------------




*Other drawbacks I am keeping in mind:
1) Relatively low pay
2) Difficult, uncooperative patient population
3) Mental health is a bit of a black box
4) Other physicians look down on you
5) The lay public thinks you do the Freud Couch thing

 

[birchswing]

The real question you have to ask when becoming a psychiatrist is who is going to come for you first: the psychologists or the scientologists? They're both out for you. And if they ever team up, watch out! Reminds me I have to think of a Halloween costume.

 

[clausewitz2]

So far we haven't seen wage decreases, but that has to be coming, right? This never works out where everyone just makes more money.

Probably will depend on the fine details of whatever legislation gets passed in the next few years aimed at expanding mental health access. Seems likely that it will take some time after enactment for the real consequences to become apparent, as is usually the way of these things. So for example regulatory language that defines NPs and PAs as the same class of provider as physicians for some critical component of the law might have dramatic effects.

 

[smalltownpsych]

Remain high?

True. We need to increase standards in a few areas such as requiring APA accredited internship for licensure and addressing the problem of large cohort professional schools. Even with some of these problems, we are still ensuring better training and education than the midlevel crowd and my fear is that many want to "increase access" by lowering standards.

 

[bd290]

Thanks again baby boomers, absolutely wonderful job.

 

[smalltownpsych]

Thanks again baby boomers, absolutely wonderful job.

Bunch of geriatric born-again hippies that have aligned with their millenial grandchildren to create the ultimate superhero - Social Justice Warrior.

 

[deleted343839]

The real question you have to ask when becoming a psychiatrist is who is going to come for you first: the psychologists or the scientologists? They're both out for you. And if they ever team up, watch out! Reminds me I have to think of a Halloween costume.

Your statement belies an understanding of both psychologists and Scientologists. But if you're a board certified psychiatrist with less than a 2-month waiting list for new patients and you're on a few insurance panels, you can still be my new bestie!

 

[Doctor Bagel]

Probably will depend on the fine details of whatever legislation gets passed in the next few years aimed at expanding mental health access. Seems likely that it will take some time after enactment for the real consequences to become apparent, as is usually the way of these things. So for example regulatory language that defines NPs and PAs as the same class of provider as physicians for some critical component of the law might have dramatic effects.

I've got to admit I'm actually fairly ignorant of the details of what was passed, but it passed in I think 2013. The main response for our psychiatric association was to change their name from Oregon Psychiatric Association to Oregon Psychiatric Physicians Association. I don't think that's quite gonna fix it.

 

[clausewitz2]

I've got to admit I'm actually fairly ignorant of the details of what was passed, but it passed in I think 2013. The main response for our psychiatric association was to change their name from Oregon Psychiatric Association to Oregon Psychiatric Physicians Association. I don't think that's quite gonna fix it.

I was referring to the current crop of bills that are circulating on the hill post the recent gun violence hullabaloo, rather than parity. Regardless, yeah, don't think name changes are an adequate response.

 

[birchswing]

Your statement belies an understanding of both psychologists and Scientologists. But if you're a board certified psychiatrist with less than a 2-month waiting list for new patients and you're on a few insurance panels, you can still be my new bestie!

I had actually written a long, serious reply, and then I thought people would find it very pedantic coming from a non-physician, so I erased it and quickly wrote a joke. It was such a bad joke that I thought about erasing it, as well. Anyhow, it was just a bad joke. But to your point, in my original serious post I wrote about the issue you mention, which is accessibility to patients and how NPs seem to work with rather than instead of psychiatrists in filling gaps when there aren't enough available psychiatrists.

 

[FlowRate]

The NP thing is not even just for "experienced nurses" anymore; see: HS graduate to Family Nurse Practitioner in 5 years. And if you've ever read the curriculum of an NP/DNP program, it's definitely nothing like residency, or even third year of medical school. Seems like the "for experienced nurses" part is getting left out.

 

[Shikima]

The NP thing is not even just for "experienced nurses" anymore; see: HS graduate to Family Nurse Practitioner in 5 years. And if you've ever read the curriculum of an NP/DNP program, it's definitely nothing like residency, or even third year of medical school. Seems like the "for experienced nurses" part is getting left out.

"For Advanced Practice Clinical Preparation, you'll complete 770 clinical hours over four semesters at a variety of settings – hospitals, clinics, community-based health centers, nursing homes"

 

[MacDonaldTriad]

With the majority of psychotropics being badly written by well-meaning primary care providers, NPs are not going change our game much. I’m not saying that NPs aren’t a problem. Some are very good and others need very close supervision and can be worse than third year med students with prescription privileges. The weak ones tend to throw medicine at every complaint and wind up in poly pharmacy land very quickly in my experience, then again, why should they be any different than weak psychiatrists.

 

[smalltownpsych]

The NP thing is not even just for "experienced nurses" anymore; see: HS graduate to Family Nurse Practitioner in 5 years. And if you've ever read the curriculum of an NP/DNP program, it's definitely nothing like residency, or even third year of medical school. Seems like the "for experienced nurses" part is getting left out.

Not only that, but to me a nurse practitioner was designed to help manage the worried-well that flood our system with colds and flus and occasionally something a bit worse at which point the nurse would be able to refer. How does anyone expect a person with less training than an MD be able to practice a specialty that requires an MD plus four years of additional training is beyond me. That's what I am seeing happen and the result is scary.

 

[HarryMTieboutMD]

The reason why we have mid level encroachment is because the AMA is absolutely the worst lobbying organization ever (despite spending the ?second most on lobbying out of any organization). They could have stopped this innumerable times but they just keep coming up with BS resolutions, etc.

 

[NontradCA]

Heh. I'm tired of guys on dates asking, "are you analyzing me right now?" And then following it up with the joke, "let me save you the trouble. I already know I'm crazy" So maybe get married before you have to tell people that's what you do. Heh. I usually say, "no, I'm not an analyst". But no one gets it. Maybe that's why I'm still single. Sent from my iPhone using Tapatalk

Sup.

 

[Leo Aquarius]

I'm not worried about encroachment with the shortages everywhere, and I mean shortages.

 

[Doctor Bagel]

Not only that, but to me a nurse practitioner was designed to help manage the worried-well that flood our system with colds and flus and occasionally something a bit worse at which point the nurse would be able to refer. How does anyone expect a person with less training than an MD be able to practice a specialty that requires an MD plus four years of additional training is beyond me. That's what I am seeing happen and the result is scary.

And NPs just out of training are being hired for really tough jobs, like jumping into busy community clinics or leading forensic ACT teams (true example). As it is, I feel like there's a ton of stuff I still need to learn having just completed residency and a fellowship. I can't imagine going straight out of school into jobs like this, treating the sickest people we have.